What are the inclusion criteria for prostate-specific antigen (PSA) screening in men at increased risk (e.g., strong family history, African‑American ethnicity, hereditary cancer‑predisposition mutations) and at what age should screening begin?

PSA Screening Inclusion Criteria

PSA screening should be used selectively through shared decision-making in men aged 55-69 years with at least 10-year life expectancy, and earlier (age 45-50) in high-risk populations including African American men, those with first-degree relatives diagnosed before age 65, and men with BRCA mutations—not as a population-wide strategy to detect the highest number of people, but rather as a risk-stratified approach that balances mortality reduction against overdiagnosis and treatment harms. 1, 2

The Correct Answer is A: High-Risk or Family History

The evidence strongly supports earlier and more intensive screening for high-risk populations rather than maximizing detection numbers or waiting for symptoms. 1, 2

Risk-Stratified Screening Initiation

High-risk populations requiring earlier screening include:

• African American men starting at age 45 due to 75-80% higher prostate cancer risk and disproportionate mortality rates 1, 2, 3
• Men with one first-degree relative diagnosed before age 65 starting at age 45 1, 2, 4
• Men with multiple first-degree relatives diagnosed before age 65 starting at age 40 1, 2, 4
• Men with BRCA mutations or hereditary cancer predisposition starting at age 40-45 1

Average-risk men should begin shared decision-making discussions at age 50-55, with the strongest randomized trial evidence supporting age 55 years from the ERSPC and Göteborg trials. 1

Why Not Option C (Detect Highest Number)

Maximizing detection is explicitly the wrong approach because it leads to the overdiagnosis and overtreatment problems you correctly identified in your question. 1, 5

• The ERSPC trial showed that 1,410 men need to be screened and 48 treated to prevent 1 prostate cancer death over 13 years, demonstrating massive overdetection. 1, 5
• Approximately 1 in 5 men undergoing radical prostatectomy develop long-term urinary incontinence and 2 in 3 experience long-term erectile dysfunction. 5
• The goal is not to find all cancers, but to prevent deaths from clinically significant disease while minimizing harm from detecting indolent cancers that would never cause symptoms. 1

Why Not Option B (Symptomatic Patients)

Waiting for symptoms defeats the purpose of screening and represents a fundamental misunderstanding of early detection principles. 1, 6

• By definition, screening targets asymptomatic individuals to detect disease before it becomes clinically apparent. 1
• Men with symptoms require diagnostic evaluation, not screening—this is a different clinical scenario entirely. 1
• The mortality benefit from screening comes from detecting organ-confined, curable disease before metastatic spread, which typically occurs before symptoms develop. 3, 6

Evidence-Based Screening Algorithm

Age 40-44 Years

• Screen only men with multiple first-degree relatives diagnosed before age 65 through shared decision-making 1, 2, 4
• Baseline PSA strongly predicts 30-year cancer risk (AUC 0.72-0.75 for advanced disease) 1, 4

Age 45-49 Years

• Screen African American men and those with one first-degree relative diagnosed before age 65 1, 2
• 44% of prostate cancer deaths occur in men in the highest tenth of PSA distribution at ages 45-49, supporting early baseline testing 1

Age 50-69 Years

• Offer screening to average-risk men through mandatory shared decision-making 1, 2, 5
• Strongest evidence for mortality benefit exists in ages 55-69 years (21% relative risk reduction in ERSPC) 1, 5

Age 70+ Years

• Discontinue screening in most men unless very healthy with minimal comorbidity, prior elevated PSA, and life expectancy >10-15 years 1, 2, 4
• Men with PSA <1.0 ng/mL at age 60 have only 0.5% metastasis risk and 0.2% prostate cancer death risk 1, 4

Screening Intervals Based on Risk Stratification

After initial PSA, use risk-stratified intervals: 2, 4

• PSA <1.0 ng/mL: repeat every 2-4 years 2, 4
• PSA 1.0-2.5 ng/mL: repeat annually to every 2 years 2, 4
• PSA ≥2.5 ng/mL: screen annually with consideration for further evaluation 2

Critical Pitfalls to Avoid

Never screen without informed consent discussing small absolute benefit, high false-positive rates (12.9% cumulative risk after 4 tests), overdiagnosis risk, biopsy complications, and treatment harms. 2, 4, 5

Do not screen men with <10-year life expectancy regardless of age, as the time to mortality benefit exceeds 10 years and screening only generates false positives and unnecessary interventions. 1, 2, 4, 5

Recognize that baseline PSA is a stronger predictor than family history or race alone for future cancer risk, supporting the value of early baseline testing even in average-risk men for risk stratification. 1, 4